application • Office Use Only
ACCESSORY STRUCTURE
Permit#: 0 21 0 ' 2T)20
PERMIT APPLICATION
i„i,„„1Quecnsbury Permit Fee: $
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net Invoice #:
Project Location: 409 Dix Ave. Queensbury, NY
Tax Map ID #: 303.16-1-6 Subdivision Name:
CONTACT INFORMATION:
• Applicant: D E C EO W
Name(s): Shaun M. Rivers — Schoder rivers Associates
Mailing Address, C/S/Z: 453 Dixon Rd. Ste. 7, Queensbury, NY
MAY 19 2CJ IL[j
Cell Phone: (518) 937-3200 Land Line: (518) 761-0417, Ext. 11 TOWN OF QUEENS BURY
Email: shaun@sraengineers.com BUILDING&DJ` a
• Primary Owner(s):
Name(s): John Harrington — Chief South Queensbury Volunteer Fire Department
Mailing Address, C/S/Z: 409 Dix Ave. Queensbury, NY 12804
Cell Phone: (518) 955-6167 Land Line: _(
Email: rt.dufour@gmail.com
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): Mike Rozell or Marcus Young
Contractor Trade: General Construction
Mailing Address, C/S/Z: Rozell Industries, 129 Park Road, Queensbury, NY 12804
Cell Phone: (518) 321-2095 Land Line: (518) 793-2634
Email: myoung@rozell ind.com
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: Schoder Rivers Associates
Contact Name(s): Shaun M. Rivers
Mailing Address, C/S/Z: 453 Dixon Rd. Ste. 7, Queensbury, NY
Cell Phone: (518) 937-3200 Land Line: (518) 761-0417
Email: shaun@sraengineers.com
Contact Person for Building & Code Compliance: Shaun M. Rivers
Cell Phone: (518) 937-3200 Land Line: (518) 761-0417 Ext. 11
Email: shaun@sraengineers.com
Accessory Structure Application Revised February 2019
• PROJECT INFORMATION:
TYPE: ® Commercial ❑ Residential
WORK CLASS:
❑ Deck,Open Porch ❑ Solar Panels(w/o rafter upgrades) ❑ Carport ❑ Cell Tower
❑ Shed ® Pavilion, Pole Barn, Canopy ❑ Dock ❑ Gazebo
❑ Detached Garage ❑ Boathouse (with or w/o sundeck) ❑ 3-Season Porch
❑ Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 2500
2nd floor:
Total square feet: 2500
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $20,000
2. If Commercial project, what is the proposed use: Pavilion for Picnics Ect.
3. Are there any structures not shown on the plot plan? NO Explain:
4. Are there any easements on the property? ❑ YES ® NO
DECLARATION:
1. I acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
2. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
3. I certify that the application, plans and supporting materials are a true and complete statement and/or description
of the work proposed, that all work will be performed in accordance with the NYS Building Codes, local building laws
and ordinances, and in conformance with local zoning regulations.
4. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
5. I also understand that I/we are required to provide an as-built survey by a licensed land surveyor of all newly
constructed facilities prior to issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: Shaun M. Rivers
SIGNATURE: . DATE: 5-18-20
Accessory Structure Application Revised February 2019